Entry-to-practice competency expectations for health justice in Canadian physiotherapy curricula: A scoping review protocol

Background: In Canada, physiotherapists are expected to possess and demonstrate several essential competencies upon entry-to-practice. Over the past decade, knowledge and skills relating to health justice have become increasingly important for healthcare professionals. However, health justice is still an emerging topic among Canadian physiotherapy programs and current curricula may be lacking explicit content to develop knowledge, skills and behaviours related to health justice which can be used to prepare students for entry-to-practice. This paper outlines a protocol for a planned scoping review. The purpose of this scoping review will be to examine existing Canadian entry-level competencies for physiotherapy related to health justice. Methods: A comprehensive literature search will be completed on four databases: OVID MEDLINE, OVID Emcare, OVID Embase, and EBSCOhost CINAHL. This scoping review will include both quantitative and qualitative methodological study designs. A grey literature search will involve advanced Google searches. Two authors will independently screen titles and abstracts to select articles for full text review. Data extraction for each selected paper will be completed independently by two authors using the proposed data extraction form. The extracted data will be presented through tables and a narrative summary that aligns with the objectives and scope of this review. Conclusion: The data collected from this proposed review will identify existing competencies and gaps related to health justice in current entry-level physiotherapy curricula. This information will assist academic programs in understanding how to integrate and identify competencies and frameworks related to health justice into Canadian physiotherapy programs to ensure students are better prepared to provide culturally competent and inclusive care and promote health justice in practice.


Introduction
Power, Privilege and Health Justice Health injustice is attributed to systemic health inequity, or the unfair health differences between a population and its groups, based on social, economic, demographic and geographic factors 1,2 .In contrast, health justice includes the optimization of health of all people, including those of low-income, minority, or racialized groups, amongst others, and requires the protection from discrimination and unfair exclusion of health services 3 .Therefore, health justice can only be attained when systems and structures exist to ensure all people have access to the resources and opportunities needed to obtain, maintain and sustain physical, mental and emotional well-being, regardless of previous or current health status 1,[4][5][6][7][8] .Health justice requires the development of strategies that integrate and promote parity in accessibility, quality of services and resources, as well as a voice within economic, social, cultural and political systems or structures 1,[4][5][6][7][8] .Evaluating healthcare systems and structures through a health justice lens offers a broad vantage point which considers and encompasses multiple elements, including but not limited to affordability (e.g. the costs of health services and a patient's ability to pay within their budget 9 ); availability (e.g. the ability of health care professionals to provide their services based on the patient's needs 9 ); and acceptability 9 (e.g. the compatibility between a provider's attitudes and the attitude of the patient 9 ).Promoting health justice requires an interdisciplinary response from all fields, including health care professionals such as physiotherapists 3 .
To fully contextualize the concept of health justice, it is important to recognize the concepts of power and privilege, and what role these concepts play in contributing to justice.Power refers to individuals who have opportunities to access resources and are given a voice 10 .Privilege occurs when individuals have an unearned advantage due to innate characteristics such as race, ethnicity, sex, and sexuality 11 .In contrast, oppression occurs when individuals have an unearned disadvantage based on the similar characteristics 11 .
Nixon 11 describes "The Coin Model'' which illustrates the seen and unseen systemic forces that contribute to privilege and oppression, and enable unfair social structures, ultimately impacting and creating inequalities within healthcare systems 11 .In this model, individuals with privilege are represented by the top of the coin, whereas individuals who face oppression are situated at the bottom of the coin 11 .Individuals on the top of the coin are traditionally presented with the power and resources to implement changes, without fully understanding the privilege they hold 11 .The Coin Model signifies the importance of having individuals on the bottom of the coin being provided with the power to address inequalities of each social structure, as they have the best understanding of the changes that need to occur 11 .However, the Coin Model can be applied to the profession of physiotherapy to analyze the areas of privilege and power.
Historically, the physiotherapy profession has failed to provide an equal and just opportunity for individuals on the bottom of the coin to have a voice 12,13 .here is a clear underrepresentation of Black, Hispanic, Indigenous, and Asian physiotherapists; a 2019 report by the American Physical Therapy Association (APTA) identified 84.3% of physical therapists were white 13 .Additionally, according to a demographic analysis of 14,135 applicant records obtained for admission cycles between 2004-2014 for Ontario physiotherapy programs, only 0.8% of the physiotherapy applicants identified as Indigenous 14 .More recently, a 2022 cross-sectional survey among Canadian physiotherapists assessing cultural competency, cultural awareness and sensitivity, and health disparities indicated low diversity among Canadian physiotherapists and a need to improve current education regarding these health justice concepts 15 .These statistics show areas where people in power can challenge the existing and historic inequalities within the physiotherapy profession.
However, until individuals from the bottom of the coin are included in the development, delivery, and evaluation of entry-level physiotherapy program curricula, and are more equally represented within all levels and sectors of the profession, the application of concepts related to health justice will not be achieved to the extent needed to dismantle the unjust structures within the physiotherapy profession.

Physiotherapy Curriculum and Health Justice in Canada
In Canada, physiotherapists are expected to possess and demonstrate a number of essential competencies upon entry-to-practice 16 .A competency is defined as, "observable ability of a health care professional that develops through stages of expertise from novice to master clinician" 17 .As outlined in

Amendments from Version 1
The second revision of this manuscript includes a number of revisions in response to the reviewer's feedback.Specifically, the research team has updated the introduction such that it includes reference to the Coin Model (Nixon, 2019) and critical theory to frame how power operates, and to set the inquiry driving this review in a manner that "sees" the full picture.Additionally, revisions to the introduction have been made such that a stronger rationale for why health justice was selected, and what concepts may be sidelined or eclipsed with this selection, is now provided for the reader.Specifically, the team includes a reference Borras (2020) who identifies that the concept of health justice offers a broad lens that considers economic redistribution, political representation, and cultural recognition, and the intersection of these concepts.Thus, the authors note that using the concept of health justice to guide the scoping review allows a framework from which multiple elements ca be concerned and reviewed, which include but are not limited to access (not only at the point of service, but also in terms of affordability and acceptability); funding; and quality of services.
In the proposed methods section, the research team modified the proposed grey literature search to be more inclusive (i.e., removing the restriction of the search to only certain countries); and proposed changes to the data extraction form such that the team will also look to identify who the authors of selected papers are, as well as if any concepts of power, voice, and privileged are acknowledged in the documents or manuscripts.Finally, revisions to terminology per the reviewer's recommendation (i.e., misrepresented was change to under-represented; and cultural safety to cultural awareness) have been made throughout the second version of this manuscript.

Any further responses from the reviewers can be found at the end of the article
the 2017 Competency Profile for Physiotherapists in Canada, competencies ensure all physiotherapists have the required knowledge, skills, and attitudes for a successful transition into physiotherapy practice 16 .Within the Competency Profile, essential competencies for entry-to-practice are organized under seven overarching domains of physiotherapy practice which include physiotherapy expertise, communication, collaboration, management, leadership, scholarship, and professionalism 16 .An essential aspect of entry-to-practice competencies is client-centeredness and the importance of understanding and considering each client's background, as well as ensuring systems exist to protect the individual's health regardless of their socioeconomic status, origin, gender, sexual orientation, religion, or culture 16 .
To align with the current global climate and the need for health care providers to be competent and mindful in delivering care, the current Physiotherapy Accreditation Standards (Accreditation Standards) for entry-to-practice physiotherapy programs in Canada were updated in 2020 by Physiotherapy Education Accreditation Canada (PEAC) 5 .The standards are required to be incorporated into the respective curricula of all fifteen accredited Canadian physiotherapy programs 5,11 .These standards ensure students enrolled in accredited Canadian physiotherapy programs are prepared to meet licensure requirements upon graduation 5 .In the updated 2020 Accreditation Standards, two new criteria related to social justice, health justice, human rights, diversity, and equity were added 5 .Specifically, criteria 5.4 states "the program demonstrates a commitment to relational accountability to Indigenous peoples and their communities in curriculum content and clinical learning opportunities for students" 18 .Moreover, criteria 5.5 states "the program demonstrates a commitment to educational and health care environments that are justice-driven and anti-oppressive that may include education related to Black and Indigenous health, critical race theory, anti-oppressive practice and evaluation of teaching materials for bias and stereotypes related to racism and other intersecting systems of inequity" 18 .The implementation of these standards is imperative within Canadian physiotherapy programs to ensure the quality of care provided by and experience of graduates is reflective of societal needs.In addition, deliberate efforts must be made to educate all members of the program in justice driven concepts.This includes evaluating biases within the physiotherapy admissions process to increase the numbers of individuals in Indigenous and other aforementioned marginalized groups accepted into the program 5 .
Despite the inclusion of concepts related to health justice, inclusivity, and cultural awareness into the Accreditation Standards, health justice is an emerging topic among Canadian physiotherapy programs, and current curricula may be lacking explicit health justice frameworks.Several other health care professions have already integrated health justice into their educational materials.For example, social justice is one of six core ethics for the social work profession in Canada and is embedded in the education of Canadian social workers as part of their scope of practice, including identification of barriers or injustices present in the community and society that may impact their patients' social wellbeing 19,20 .Similarly, Canadian nursing students' curricula feature themes related to social justice such as health equity, equitable distribution, and freedom from bias 15 .Specifically, the entry-to-practice competencies of Canadian public health nursing considers social justice and cultural safety as a requisite in the practice of public health nurses 21 .
Due to the importance of health justice in the context of Canadian physiotherapy education and practice, and the recent inclusion of its concepts in the Accreditation Standards, further research is required to examine how health justice has been integrated into entry-level curricula to date and to identify opportunities for improvement.Thus, the primary objective of this paper is to examine existing Canadian entry-level competencies for physiotherapy related to health justice.The secondary objective is to examine the existing entry-level competencies for physiotherapy related to health justice in countries other than Canada 22 .The last objective is to evaluate how existing entry-level competencies related to health justice in Canadian physiotherapy practice compare to those of other countries.The overall purpose of this paper is to clearly outline explicit themes and concepts related to health justice currently being delivered, and to identify gaps and areas of improvement using a critical lens.According to critical theory, this lens includes a recognition of the fact that power is structural, and these structures are often invisible; social structures are human constructs, and often built to achieve certain ends; there is a need to focus on real inequities in society and for these inequities to persist the work of maintaining privilege and power is ongoing; and critical theory is ultimately about action for those who are victims of oppression, stigma and prejudice 23 .Thus, the authors recognize that due to the existing and historical structures of power and privilege within the profession, current practices identified through the research for this paper, may not be indicative of what should be implemented in all Canadian physiotherapy curriculums, as the perspectives of the individuals on the bottom of the coin, those who are underrepresented and without a voice in the profession may be lacking in existing practices.As such, the results of this project will also recognize what voices and perspectives are missing to help inform next steps.

Methods
The reporting of the final scoping review will be guided using the PRISMA Extension for Scoping Reviews (PRISMA-ScR).
The methods of this scoping review will be based on the proposed methodological stages of a scoping review by Arksey and O'Malley, Levac et al., Joanna Briggs Institute, and Peters et al. [24][25][26][27] .The stages will include the following: 1. Identify the research questions using the Population, Concept and Context Framework.
2. Publish the protocol for the scoping review.
3. Carry out the search and identify relevant studies.
4. Select the studies that meet the inclusion criteria.
5. Chart the extracted data.Context: This scoping review will include articles addressing curricula for entry-to-practice physiotherapists in Canada, and other countries.

Search strategy
The search strategy aims to identify published and unpublished literature.A primary search was conducted in Ovid MEDLINE (1946 to February 2022), with "physiotherapy" and "curriculum" searched as key terms.Terms such as, but not limited to, "health equity," "health care disparities," and "social determinants of health" were used to represent the concept of "health justice."Terms derived from the titles and abstracts of relevant studies were integrated to build a comprehensive search strategy.The full search strategy for Ovid MEDLINE has been included in Table 2. Two librarians, SU and NB, within the Faculty of Health Sciences at McMaster University, Hamilton, Ontario were consulted to refine and improve the comprehensiveness of the search.
In addition to Ovid MEDLINE, EBSCOhost CINAHL, Ovid Embase, and Ovid Emcare will be searched.The search strategy and the specific subject headings and keywords used will be adapted for each database used in the search.Additionally, a review of the reference lists of included articles will be undertaken to identify articles not captured in the initial searches.Given the novelty of the topic, a grey literature search will be performed to find relevant information not captured in the existing published literature.To be inclusive of all available resources, the advanced Google searches will not be limited to any country but will limited to the first five pages of results.
Only articles published in English will be included in this scoping review.Studies published in the year 2011 and onwards will be included in this scoping review.This limit was selected because literature demonstrates that there was greater dialogue regarding the integration of health justice related competencies into physiotherapy program curricula beginning in 2011 28 .

Study selection
After completing the search strategy in Ovid MEDLINE, EBSCOhost CINAHL, Ovid Embase, and Ovid Emcare, all articles will be imported into a reference management software, Mendeley, and then uploaded into a review management software, Covidence (note: a freely available alternate software is rayyan), to remove duplicates.Furthermore, any duplicates identified during abstract screening, full text screening, and data extraction will also be removed.Titles and abstracts will be screened and reviewed by two independent reviewers, with partners agreed upon in advance by members of our research team, to ensure accuracy.Titles and abstracts that do not explicitly address physiotherapy and physiotherapy competencies will be excluded.Articles selected for full text review after abstract and title screening will be retrieved and reviewed by pairs of reviewers for inclusion and to determine their eligibility.A full report of included and excluded articles will be addressed in a PRISMA flow chart, outlining the reason for exclusion and inclusion in our final scoping review.Conflicts related to inclusion at either the title and abstract stage or full text stage will be discussed amongst the pair of reviewers to come to an agreement.Finally, disagreements will be resolved by discussion between the two reviewers or by consulting with a third reviewer.

Data extraction
Four independent reviewers will extract data from the included articles using the process outlined in the Joanna Briggs Institute Reviewers' Manual 20,29 .A data extraction tool was created by the four reviewers and will be used during the data extraction process.A draft of the form can be found in Table 3.The key findings of each paper, as well as the country where the research completed will be additional outcomes used to describe the existing literature.As the intention of scoping reviews is to provide a descriptive overview of the literature, scoping reviews do not require a critical appraisal of individual studies; therefore, a risk of bias assessment will not be completed on the included papers 22 .
If revisions are made to the data extraction form, they will be reported in the final scoping review.From the studies selected for inclusion, authors will be contacted if required data is missing.Reference libraries will also be screened amongst included papers.Lastly, to mitigate disagreement between reviewers during the data extraction process, a third reviewer will be consulted if discrepancies are identified.

Data presentation
The extracted data will be synthesized to include summary tables and graphs which reflect the frequency of key concepts described in the literature; as well as the countries or locations and the populations represented in the included studies.Additionally, the research team will review the aim and key findings of each included study and to identify if any common trends exist.These findings will be reflected in the narrative of the paper, and where appropriate, included as tables or graphs.

Study status
At the time of protocol publication, the research team has completed searches in Ovid MEDLINE, EBSCOhost CINAHL, Ovid Embase, and Ovid Emcare using the proposed search strategy.In total 5081 records were identified across all databases.After removing duplicates, 4379 studies were uploaded to Covidence.The research team has now started abstracts and title screening.

Conclusion
This protocol details our plan to examine the current literature on existing Canadian entry-level competencies for physiotherapy related to health justice.Furthermore, it will involve searching for trends of current recommendations and practices related to health justice for entry-level physiotherapists in other countries to compare their health justice related recommendations with that of Canada's.After completing the scoping review, we hope to publish our results and present our findings to other health care professionals.The goal of this scoping review is to identify gaps related to health justice in current entry-level physiotherapy curricula.The use of a scoping review is a strength in this study as it is an ideal study design for emerging topics in research.Additional strengths of this study include the use of PRISMA-ScR which will provide a transparent and replicable outline of the steps in our research process.While the parameters for conducting a grey literature search will be limited, including unpublished literature will ultimately help to create a more comprehensive search.This novel area of research has great potential for making significant impacts on the Canadian physiotherapy profession and curricula.The limitations of this study include only searching four databases; limiting inclusion requirements to papers published after 2011, and papers published only in English.In regard to grey literature, the search will be limited to the first three pages of results from Canada, the United States of America, Australia, and New Zealand.Furthermore, other potential limitations may arise due to a lack of resources and limited time to conduct the study.

Open Peer Review
Current Peer Review Status: The relevance of this study is significant, especially given the evolving healthcare education where competencies related to social justice, equity, and inclusivity are becoming increasingly important.By focusing on Canadian physiotherapy programs, this scoping review has the potential to influence curriculum development, ensuring that future physiotherapists are better equipped to address health disparities and promote equitable healthcare practices.

Major Points:
The study addresses an important and emerging topic in physiotherapy education.The authors focus on the integration of health justice into the curriculum, citing its inclusion in the updated Physiotherapy Accreditation Standards as a key reason for its importance.However, while these standards provide a framework for curriculum development, they do not fully capture the unique relevance and necessity of health justice within the physiotherapy profession.

○
The protocol demonstrates an accurate methodological approach, particularly with the comprehensive search strategy across multiple databases.However, whether articles from low-and middle-income countries, would be included is not clear.

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The data extraction form is well-detailed; however the study would benefit from a more ○ critical appraisal of the literature.

Minor Point:
The article's current emphasis on accreditation standards as the primary rationale for integrating health justice into physiotherapy curricula does miss the opportunity to fully articulate these broader, profession-specific reasons.By expanding on the importance of health justice from a physiotherapy perspective, the authors could strengthen their argument, making a more compelling case for its inclusion as a core competency.
○ Is the rationale for, and objectives of, the study clearly described?Yes

Are sufficient details of the methods provided to allow replication by others? Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Physiotherapy, bioethics, Education, Cardiorespiratory Physiotherapy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Filip Maric
UiT The Arctic University of Norway, Tromsø, Norway Dear authors, Thank you for the opportunity to review this interesting study protocol and the work you are doing in the important field of health justice.Your outlined research is highly relevant to advance justice as a central concern in health and health care yet by no means an easy field of inquiry.As a result of my reading, and based on my background in both critical physiotherapy, planetary health and environmental physiotherapy, I can offer observations on issues pertaining to the way you work with your central concept of health justice, two methodological pointers, and some minor corrections.I hope these will be valuable in further refining your study plans and their subsequent implementation.I recommend making some of the smaller changes that I mention throughout my review but leave whatever you perceive as larger issues and open questions to be handled at your discretion.

The concept of health justice
One of the main challenges that your work is facing is grappling with the very concept of health justice.Overall, it seems as though a preceding study could have been one exploring the many existing definitions of the concept, or the many concepts that could be understood as relating to health justice (where the latter might function as an umbrella term?), which could then inform a curricular or literature review.Setting aside this substantial turn in focus for a potential future or parallel study, I will try to connect this topic to specific places in your writing: Inclusion criteria, concept: Where is your 'aforementioned definition of health justice'?Is it the statement in sentence two in paragraph 1 of the introduction?Should this maybe be additionally represented in a separate box of its own (if you feel this is your penultimate definition)?Or are you aiming at something like a broad 'concept field', to the understanding of which your scoping review will contribute via the use of health justice as an umbrella term?This inclination is indicated, at least, in the notion of 'concepts related to health justice' and, under 'data extraction' when you write that 'The main outcomes of interest that will be collected during data extraction are the concepts related to competencies associated with health justice in entry to practice physiotherapy curriculums'.You might also want to review the 'competencies associated with health justice' as this specification seems to add another layer of complexity, or a different set of concepts altogether.I realize that you are interested in 'competency expectations' but I would argue that these would have to be grounded on a specific definition or understanding of health justice, which I am not sure you have quite established yet.
Somewhat in line with this, I would also suggest rephrasing the related point in the data extraction tool (would 'data collection tool' be a better term in a critical theory-informed study that is conscious of the role of social and ecological extractivism in colonialism?):'Which concept related to health justice was included in the article'.In line with my latter point, you might also find that you are looking for 'concepts related to competencies associated with health justice', which might be an entirely different set of concepts.
To me, 'which concept related to health justice was included in the article', seems the pivotal question to your whole study.Which concepts do you relate to health justice?What, for example, would you do with articles discussing the use of (critical) dis/ability theory in PT education, or even just universal design (which could readily be understood as relating to health justice for otherwise abled people) or the ICF model, or LGBTQ+ issues, or (the representation of) counter/cultural understandings of health, illness and care (as an enactment of health justice).The list goes on.
From an environmental physiotherapy or planetary health perspective, a central extension to your conception of health justice is briefly indicated in the introduction section 1, paragraph 1, with the mention of geographic factors.Should maybe environmental factors and environmental in/justice be included as a critical element of health justice in light of past and present eco-social crises?Social and environmental injustice have also always been inseparably intertwined with colonialism and affect the health of people to this day.You could also include ecological determinants of health among 'concepts related to health justice', maybe even certain notions of sustainability (which point to the inclusion of future generations in our considerations of justice).
Beyond this, the common, anthropocentric definition of health justice advanced in your study protocol reflects an attitude that is extensively addressed in the literature as no longer tenable, namely, the foregrounding of human concerns (albeit largely the concerns of some humans over those of others) over concerns for other-than-human species, ecosystems, etc.The effects of this attitude are dramatically present in the currently ongoing sixth mass extinction (i.e., the exacerbating massive loss of plant, insect, and animal biodiversity), among other large-and smallscale ecological crises.In the following article, I have tried to allude to the way in which our very definition of (health) justice might have to expand 'to do justice' to the crises of our time in a healthcare context: Maric, F Another point in relation to your use of the concept of health justice is whether you are focussed on a potentially overly static definition of justice, as opposed to taking to justice as a kind of ongoing praxis, a constant engagement, negotiation and re/evaluation, acknowledging ongoing shifts in stakeholders, power, interests, needs, etc etc.I am not a specialist in this particular field, but I could imagine that an inquiry into justice as a praxis could yield itself to an exploration of relevant competencies (like e.g.knowledge of and skills in the application of critical theories) in a slightly different way than a more static understanding of justice (e.g. when access, availability, affordability for all are presumably achieved).
Intro section 2, paragraph 3-5: I appreciate your inclusion of Nixon's article on the Coin model but wonder whether it corresponds well with the heading to the subsection under which you have grouped this.If you finish the subsection with the sentence you are finishing it with now you give the impression that your primary focus is on dismantling health injustice within the PT profession, yet, I think this is maybe just part of what you are aiming for.If you are trying to explain the Coin model, or, precisely, the concepts of power, privilege and health justice using an inward look into the PT profession, then maybe separate this out via an additional subsection heading along the lines of 'Understanding power, privilege and health justice: the example of the PT profession'.Another option might be to move your current first paragraph under 'Introduction' and then rephrase the existing subsection heading as suggested here, or similar.Then make sure you round off this subsection by stating that or how this provided you with an example to illuminate the meaning of power, privilege and health justice.

Methodology point 1: A critical theory lens or framing
Intro section 2 paragraph 5: I suggest separating the last portion of this paragraph into a subsection of its own, titled something like 'A critical theory framing'.The last sentence of the remaining first portion of the paragraph should then maybe end on 'using a critical theory lens' to more accurately reflect a possible lens you might adopt, which is then further explained in the other, now sectioned-off portion of the paragraph where you explain what lens or theoretical framework you will be using in your scoping review.
The issue that presents itself in this paragraph is the same as the one highlighted by the previous reviewer, which is the relative lack of theoretical framing of your study so far.This is also related to the question of whether or under what conditions scoping reviews are sufficiently well aligned with 'critical theory' to begin with, given that, as you write under 'data extraction', 'the intention of scoping reviews is to provide a descriptive overview of the literature, scoping reviews do not require a critical appraisal of individual studies', whereas the intention of critical studies is to uncover, precisely, power and in/justices in play.With some smaller rephrasing, I would argue you can still claim the latter as the exclusion of health justice topics might itself be considered an injustice.In this case, however, you would maybe not be doing purely descriptive, but somewhat critical theory-informed work, which I think is the direction you are gradually heading.

Methodology 2: Inclusion criteria, population
You mention that you will be collecting 'articles that focus on educating physiotherapy students in entry-to-practice physiotherapy programs', and under 'context' 'articles addressing curricula for entry-to-practice physiotherapists'.
This got me wondering what these articles might be, and how many there might really be for you to analyse.Further, I wonder whether these articles will really be the best places where relevant concepts and competencies will be reflected?Or should you be looking at curricula instead?Or maybe even further down, the teaching content within one institution?Or maybe I misunderstood and you will also be looking at curricula and relevant guidelines? it might be worth clarifying, potentially even just by changing the word 'articles' to 'literature' as a broader term.

Minor issues
Search strategy, final paragraph, suggestion: 'there was greater dialogue regarding the integration of health justice related competencies into physiotherapy program curricula in the English-language literature beginning in 2011'.

○
Intro paragraph 2: privilege and oppression do not only occur at individual but also at group level, so the sentences there should likely read '…occurs when groups or individuals have…' plus setting 'dis/advantages' in the plural as these rarely come in the singular.

Stephanie Nixon
Department of Physical Therapy, University of Toronto, Toronto, ON, Canada This is an important inquiry that stands to contribute to the critical theoretical research emerging within the field of physiotherapy (and beyond).My congratulations to the authors on tackling this fraught and challenging topic.Below I propose several ways to ensure that the assumptions underpinning this inquiry are lined up to advance transformative change as opposed to unwittingly reproducing inequity.In short, my reflection is that, technically, the scoping study plan looks solid.However, the inquiry is missing a rigorous theoretical basis in terms of understanding how power operates, which is both common and dangerous.Let me explain.

MOST IMPORTANT DEAL-BREAKING POINT:
Because critical theoretical work applying an antioppression lens within the field of PT is relatively modest, it means that we don't necessarily have a strong tradition or set of expectations to guide us, and what ends up happening is that common sense or surface-level understandings are taken as acceptable and normal.By "critical", I am referring to research that is concerned with power, and the ways that it gives an advantage to some people, ideas, and ways of being over others, leading to inequities.The proposed inquiry is critical by definition with its focus on health justice, which is about power.As such, it is necessary to have a theoretically rigorous starting point for the inquiry in order to avoid the very common trap of unwittingly reproducing inequities while undertaking work designed to uproot them.At present, the framing of how power operates as the basis for understanding health justice is largely underdeveloped, which sets up serious problems for this inquiry.In a nutshell, we are missing the coins (i.e., the actual intersecting systems of inequality that produce inequity and injustice) and the top of the coin (i.e., the role of people in positions of unearned advantage or privilege in upholding and reproducing these inequities through their actions, and in this case, through their fields) (please see https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7884-9) 1 .This shortcoming is not unique to this protocol -my experience has been that this is the dominant way of thinking about equity and social justice within the health sphere broadly (i.e., we've been taught that this is the common sense way to think about justice).But it's necessary to bring in the source of inequities, and our complicity in them as a field, in order to set up this inquiry in a way that can "see" the full picture.Otherwise, we're only looking for and at the bottom of the coin -i.e., groups who are marginalized -and reproducing the faulty idea that this is the problem to be addressed.This inquiry needs an explicit framework for entering into the study that understands the problem as intersecting systems of inequality (by which I mean the many 'isms') and the complicity of people on top of those coins in upholding these unjust systems.POINT 2. From this more coherent starting point, there are a number of concepts one could put under the spotlight.I was intrigued by the decision to focus on "health justice".In my wider antioppression work within the health sciences, I have not found this to be a common framing.I'm not suggesting that it needs to be changed.However, I am calling for a deeper rationale for why this concept is the focus as opposed to many other aspects of anti-oppression and social justice that are relevant in the context of PT education.And reflection on what gets foregrounded by this particular focus and what gets sidelined/eclipsed.
POINT 3. The choice to consider only grey literature from certain regions of the world seems curious to me for a study interested in justice.There is a tendency to see 'high-income countries' as more advanced and holding more expertise than 'less developed' countries -yet some of the most important justice movements are taking place in those settings.Given the focus on colonization as part of the health justice concept (as linked to the new PEAC criteria) within this inquiry, I encourage the authors to consider the implications of privileging grey lit from countries that are the winners of colonization and foreclosing on possible contributions from other settings.Granted, language may be an issue with the focus on English texts only, but I propose that that is a pragmatic limitation of the inquiry and not a reason to prevent the possibility of learning from a wider range of settings.
POINT 4. Some more minor points that may be adjusted in attending to point 1: Intro para 3 -'cultural awareness' likely should be 'cultural competency' or 'cultural safety' is better -the assumptions about power and complicity in these different concepts are important and need to be aligned with your elevated conceptual analysis underpinning the study Reviewer Expertise: anti-oppression within the health sphere I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.
Nixon notes, the authors recognize this topic is challenging and still emerging in the physiotherapy profession.The lack of literature that addresses anti-oppressive, and justicedriven concepts within the profession, and more specifically related to entry-to-practice curriculum development and implementation, presents an important opportunity for Canadian physiotherapy educators who will need to prepare students to lead the transformative change in the profession noted.Additionally, the main objective of this review is to identify how health justice topics have been integrated to date, identify gaps, and provide recommendations for improvement in entry-level curricula.The reviewer provided a reference to their work on the Coin Model (Nixon 2019) to encourage the research team to state the theoretically grounded starting point for the proposed review, and to identify there was a risk of upholding and reproducing inequities through the outcome of the proposed review if not addressed.The research team appreciated this feedback, and acknowledges, a possible outcome of this scoping review may be to illustrate an imbalanced, or lack of reporting of both sides of the coin exists in the literature and existing curriculum documents.However, to the authors' knowledge a systematic literature review, which includes academic and grey literature, related to anti-oppression and justice driven concepts in entry-level physiotherapy curricula in Canada has not been completed.Thus, while the results of this scoping review may confirm the reviewer's impression, they may also illustrate where intentional, collaborative changes can occur in curriculum development and implementation such that underrepresented theories, voices and lived experiences might be more explicitly included in future entry-to-practice physiotherapy curricula.Below, we have described the changes the review team has made to the proposed protocol, and where applicable provide our rationale for the inclusion of specific content or focus.

Missing an explicit framework
The authors acknowledge that the first version of the protocol did not fully frame how power operates and the influence it carries in understanding health justice.We recognize much of what was alluded to in the protocol aligned with key principles of critical theory, but this was not explicitly stated as a guiding framework.However, we also acknowledge the critiques of critical theory which include an over-simplification of power relations (i.e. a binary between those who hold power and those who do not); and lacking explanations about why power persistently creates haves and have nots, and how people facilitate the process (Nichols, 2022).As such, the protocol now references a critical theory lens, as well as Nixon's coin model to frame how power operates, and to set the inquiry driving this review in a manner that "sees" the full picture.Revisions to the protocol now include an enhanced introduction, which will ground the reader with a discussion of the Coin Model (Nixon 2019), as well as a discussion of which voices may be under-represented in the physiotherapy profession and in the literature identified through the review process; and an enhanced data extraction tool that explicitly identifies who the authors are, identifies the developers of any curricular content delivered, identifies the deliverers of any curricular content delivered, as well as if the concepts of power, voice and privilege have been acknowledged or discussed in the included papers.This enhanced data extraction form will help the research team be intentional about also identifying what is missing from the existing body of literature.

1.
Understanding and locating what is identified in the scoping review The authors acknowledge that an important element of this scoping review is to identify themes and concepts that are explicit but also to see beyond what is written to capture what is silent or missed in the published literature.As such, and as noted above, the data extraction tool now includes a section to identify if power and privilege have been acknowledged in the paper, who the authors of the work are, as well as who was involved in the development, delivery and /or evaluation of any curricular content presented.

2.
Deeper rationale for health justice The review team acknowledges that the concept of health justice is not a common framing for anti-oppressive work in the health sciences.However, Borras (2020) identifies that the concept of health justice offers a broad lens that considers economic redistribution, political representation and cultural recognition, and the intersections of these concepts.Thus, grounding this review with the concept of "health justice" provides a framework from which multiple elements can be considered and reviewed as part of the literature search, data extraction and theming processes.These elements include but are not limited to access (not only at the point of service, but also from a lens of affordability and acceptability from the client's perspective); funding; and quality of services.A stronger rationale for using this concept as a frame has now been provided, as well as what gets foregrounded and what might be sidelined or eclipsed in this context.

Updated grey literature search
The perspective of the reviewer on the approach to the grey literature was greatly appreciated.Based on the feedback from the reviewer, the authors have revised their approach to the grey literature search to be more inclusive, and not restrictive to only a specific list of countries.However, the limitations of including English only resources will be acknowledged as part of the study findings once the study is completed. 4.

Other considerations
The other considerations identified by this review have also been addressed:

5.
Cultural awareness -when the word was not used specifically by the cited literature, we have revised the protocol to reflect cultural safety; thank you for identifying this important change to terminology as use of terms is changing; the team has also acknowledged the changing terminology in the review.

○
Misrepresented -Thank you for asking for clarification on this concept; this term has been replaced with 'underrepresented' which aligns with the findings in the cited surveys ○ Criteria -this language has been updated to reflect the singular criterion at the two ○ points The revised protocol has been uploaded, and the authors look forward to continued discussion on the review and the concepts included, as dialogue and continued learning is an important step in the process of identifying and challenging our profession to consider how to ensure our entry to practice curricula can implement the new standards and expectations that will help to transform the profession in the future.

Version 2 Reviewer
Report 29 August 2024 https://doi.org/10.21956/mep.20638.r33459© 2024 jiandani m.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.mariya jiandani 1 KEM Hospital, Mumbai, India 2 Physical Therapy School & Centre, Seth G S Medical College and KEMH, Mumbai, Maharashtra,IndiaThe article outlines a protocol for a scoping review aimed at examining the current state of entryto-practice competencies related to health justice within Canadian physiotherapy curricula.The study is positioned within the broader context of increasing recognition of health justice as a critical component of healthcare education.It aims to identify existing competencies, highlight gaps, and provide insights for integrating health justice more explicitly into physiotherapy education.

○ Intro paragraph 4 :References 1 . 1 Reviewer
First word in second sentence should likely read 'There' ○ Correct reference 23: The title of the book Physiotherapy Otherwise is currently incorrect.○ Best of luck with your further writing.I look forward to reading a new version of your study protocol and, eventually, your review findings and follow-up research.Maric F, Nicholls DA: Environmental physiotherapy and the case for multispecies justice in planetary health.Physiother Theory Pract.2022; 38 (13): 2295-2306 PubMed Abstract | Publisher Full TextIs the rationale for, and objectives of, the study clearly described?YesIs the study design appropriate for the research question?PartlyAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?Is the rationale for, and objectives of, the study clearly described?Not applicableIs the study design appropriate for the research question?Not applicableAre sufficient details of the methods provided to allow replication by others?Not applicableAre the datasets clearly presented in a useable and accessible format?Not applicableCompeting Interests: No competing interests were disclosed.Reviewer Expertise: anti-oppression within the health sphere I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.VersionReport 25 May 2022 https://doi.org/10.21956/mep.20484.r32007© 2022 Nixon S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Table 1 . Inclusion and exclusion criteria.
Concepts related to health justice (e.g., social justice, affordability, availability, acceptability, social determinant of health, cultural competency)

Table 2 . Sample search strategy. Ovid MEDLINE
mp. or exp Physical Therapists/ or physical therapy specialty.mp.or exp Physical Therapy Specialty/ or exp Physical Therapy Modalities/ or physical therap*.mp.or physiotherap*.mp.202,521 #2 competency based education.mp.or exp Competency-Based Education/ or curriculum.mp.or exp Curriculum/ or curricul*.mp.or competenc*.mp.or entry-level*.mp.or clinical competence.mp.or exp Clinical Competence/ or exp Education/ 951,996 #3 health equity.mp.or exp Health Equity/ or health care disparities.mp.or exp Healthcare Disparities/ or health status disparities.mp.or exp Health Status Disparities/ or social determinants of health.mp. or exp "Social Determinants of Health"/ or health services accessibility.mp.or exp Health Services Accessibility/ or exp "Delivery of Health Care"/ or culturally competent care.mp.or exp Culturally Competent Care/ or universal healthcare.mp.or exp Universal Health Care/ or patient centered care.mp.or exp Patient-Centered Care/ or exp Social Justice/ or health justice.mp.or equity.mp.or health inequit*.mp.or universal health*.mp.or (health* AND (accessibility.mp.or affordability.mp.or acceptability.mp.or availability.mp.)) 1,294,805 #4 #1 and #2 and #3 3378 #5 Limit #4 to (yr="2011-Current") and (English) 1731

Table 3 . Draft data extraction tool. Data Collection Form Reviewer of Initials Date of Extraction Article Identifiers Title Author name (Last, first) Who are the researchers in this article: Title, job role, associated department Where are the researchers from? Date of Publication Article Country of Origin Eligibility Criteria Does this article include Physiotherapy education concepts
? ☐ Yes ☐ No Does this article have entry-level physiotherapy concepts?☐ Yes ☐ No Is this article's text in English?☐ Yes ☐ No Is this article published from 2011-present?☐ Yes ☐ No Does this article include concepts of health justice?☐ Yes ☐ No

Key Definitions and Objectives Were there any key definitions outlined? If so, what were they? Which of the 3 objectives in our thesis does this article address?
Information on authorship, article type, article purpose, inclusion criteria, population, setting, study design and methods, and key findings relevant to the Population, Concept, Context question will be extracted.The main outcomes of interest that will be collected during data extraction are the concepts related to competencies associated with health justice in entry to practice physiotherapy curriculums (i.e., competency-based education; entry level competencies; education level; health equity; accessibility; affordability; and acceptability).
., & Nicholls, D. A. (2022).Environmental physiotherapy and the case for multispecies justice in planetary health.Physiotherapy Theory and Practice, 38(13), 2295-2306.https://doi.org/10.1080/09593985.2021.1964659 This is IMPERATIVE in order for you to be able to understand and locate what you find in the scoping study, vs taking what you find at face value as right and good.As such, this power analysis/framing is about us shining a light on not just how to make things more just by being outward looking, but also looking inward at our own role as a profession in upholding these systems of inequity -i.e., cleaning up our own house.My guess is that mostly what you'll find in this review is that there is a LACK of research/guidance about the coin and top of coin, and lots about bottom of coin -this needs to be made visible.And that's why you need a coherent critical orientation going in -i.e., to be able to see what's missing.Otherwise, you are setting up the inquiry to report on the bottom of the coin details found in the literature as if it's what we SHOULD be doing, vs locating those findings in the context of a coherent anti-oppression analysis that can show what is helpful and also what is missing.This has important implications for aspects of the study protocol.E.g., from Table1inclusion criteria: "Concepts related to health justice (e.g., social justice, affordability, availability, acceptability, social determinant of health, cultural competency)" -what about our settler colonial roots as both a country and a profession, racism, ableism, heterosexism and lots of other isms that play out in PT which PRODUCE and MAINTAIN the inequities that health justice is concerned about?You need to actively look for these (and others aligned with a more coherent power analysis) in order to be able to state with confidence both what you find and also what you've found to be missing/invisible in your search.This is what is called for in the two new PEAC criteria.I also spell this rationale out in this 10-min video here: https://www.youtube.com/watch?v=a30a_NiT5zc&list=PLNWUsONW1NHKByYnDkqHAFpoCXcGuIGa4&index=6 and this 23-min video here: https://vimeo.com/644652449/644179039).

Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? No Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not
Unlinked to power analysis, but a friendly heads-up that 'criteria' should be the singular 'criterion' at two points ○ I've suggested an important shift above, which will hopefully be received in the spirit of collectively holding ourselves to account within PT (and healthcare broadly) as we try to do transformative change-making work toward justice.I am in this struggle with you, also learning and unlearning.My very best wishes for your important work!
○ Intro para 1, line 5 -"misrepresented" -I am unclear what this might mean ○ Introapplicable Competing Interests: No competing interests were disclosed.